by renditioner » Wed Aug 27, 2008 09:12 am
A lot of you may be confused with what is coinsurance after deductibles. It is true that many individuals purchase health insurance without knowing that co-payment and deductibles are two different things. If you are purchasing health insurance you must be aware of what the policy holds for you and clearly you must be aware of the different terms used and what they mean.
What is a deductible and co-insurance?
Deductible: This is the amount that you are responsible to pay before your insurance company starts paying when a claim is made. Your premium value is also determined by the deductible that you choose. The higher the deductible, the lower will be your premium.
Co-insurance: Say you have a deductible of 2000 and the hospital bill comes around at 20, 000. As a rule you have to pay off the deductible, i.e. 2000 out-of-pocket before the health insurance company begins to pay. So you still need 18000 to pay off the rest of the bill. If you have a 80/20 co insurance and the insurance company pays 80%, you need to make 20% of the remaining 18, 000. This means that your out-of-pocket costs would be deductible + the percentage of co-insurance you have agreed upon.
Co-insurance also has a stop loss clause that lets you pay your share of the co-insurance up to a certain limit for that year after which the insurance company bears 100% of the claim amount.
The difference between coinsurance and deductible is not clear to a lot of individuals. This may create a lot of confusion when you make a claim. But if your policy has this clause you must clearly understand what will be your contribution after a claim is made. Ask your agent to explain what portion you will have to pay and what portion your insurer would pay and how both co insurance and deductible would come into play.
Co-insurance: Say you have a deductible of 2000 and the hospital bill comes around at 20, 000. As a rule you have to pay off the deductible, i.e. 2000 out-of-pocket before the health insurance company begins to pay. So you still need 18000 to pay off the rest of the bill. If you have a 80/20 co insurance and the insurance company pays 80%, you need to make 20% of the remaining 18, 000. This means that your out-of-pocket costs would be deductible + the percentage of co-insurance you have agreed upon.
Co-insurance also has a stop loss clause that lets you pay your share of the co-insurance up to a certain limit for that year after which the insurance company bears 100% of the claim amount.
The difference between coinsurance and deductible is not clear to a lot of individuals. This may create a lot of confusion when you make a claim. But if your policy has this clause you must clearly understand what will be your contribution after a claim is made. Ask your agent to explain what portion you will have to pay and what portion your insurer would pay and how both co insurance and deductible would come into play.
What does coinsurance after deductible mean?
Coinsurance after deductible means that under a health insurance policy the insured will cover a fixed percentage of the covered expenditures after the deductible has been paid. This is almost similar to co-pay except that in co-pay the insured is supposed to pay a fixed dollar amount instead of a percentage when the medical service is delivered.
Related Readings:
- Difference between co-pay and co-insurance
- What is co-insurance stop-loss?
- About co-insurance
- Co-insurance explained
I was wondering whether its coinsurance after deductible or is it the whole insurance claim..Say I have a deductible of 500$ and a 70/30 coinsurance policy .When does the coinsurance come into play?After I pay the 500$ deductible or for the whole sum of the insurance claim?
Posted: Sat Nov 13, 2010 05:57 pm Post Subject:
Insurance companies have to have their own network of providers under the policies the insurance companies have right?
Posted: Sun Nov 14, 2010 03:26 pm Post Subject:
Not sure exactly what question you are asking Nicholas. But in HMO and PPO plans, each insurance company creates its own network of providers (it is not uncommon for physicians to be members of four or five different HMO/PPO networks).
The HMO/PPO then publishes its list of providers for the subscribers -- used to be mini-telephone book documents, but now it's all posted online. If in an HMO, one must voluntarily select a PRIMARY CARE PROVIDER (MD, DO, RNP, PA) as described by the plan. The PCP may be changed as often as once per month (effective the first of the following month in most cases). If not voluuntarily selected, the HMO will assign the subscriber to one close to the person's residence address. That PCP must provide most patient services or obtain referrals to network specialists for the subscriber. HMO primary care providers agree to accept the HMO's "negotiated" rates (kind of like having a gun held to your head and being told what you will accept) plus the subscriber's copay at the time of service. The additional "carrot" for the HMO PCP is something called "capitation" -- a regular monthly payment for each subscriber enrolled in their practice (in SoCal in 2010, typical capitation rates for an MD are: Male adult, $20-$22, Adult female $23-$27, child under age 13, $20-$25, child age 13 - 18, $22-$27) and they get the money whether they ever see the patient or not. Pays for rent, utilities, an office secretary or other staff person, but is not expected to be the PCP's own compensation. Service billings for patient visits and copayments take care of that.
In a PPO, the subscriber is not limited to a PCP (although they are encouraged to establish a similar relationship), and they are not limited to the network of physicians. They may choose to go outside the network -- such as when the doctor they've been seeing for years is not a member of the network -- but doing so always costs more money out of pocket, because in the network, the providers have agreed to a contracted rate of payment from the PPO plus a copayment from the subscriber at the time of service. There is NO CAPITATION in a PPO, but physicians receive a higher level of compensation on a FEE-FOR-SERVICE basis. They are allowed to bill for more services than an HMO physician. But not much more. And they don't get paid a lot more either.
Honestly, when I see the pitiful amount of money an HMO or PPO physician or surgeon (or hospital or clinic/laboratory) gets from the HMO/PPO compared to the premiums people are paying, I wonder why any young person in America would want to become a doctor. Leave medical school $300,000+ in debt and have to work for at least 20+ years as an HMO/PPO physician to pay it off. Not appealing to me in the least.
Posted: Thu Nov 18, 2010 01:23 am Post Subject: 80% coinsurance after deductible
I would like to know 80% coinsurance after deductible means
Posted: Sat Nov 20, 2010 01:27 am Post Subject:
If we're talking about health insurance, then "80% coinsurance after the deductible" means that after you've satisfied the stated deductible in your policy, the insurance company will pay 80% of your covered claims -- up to the stated "stop loss" or "out-of-pocket" limit. After that, covered claims are paid 100%.
Let's say you have a medical expense of $1,000. If your deductible is $500, you pay that amount. Of the remaining $500 loss, your insurance would pay $400, you pay the other $100. When your next claim comes in, the insurance company will pay 80% of that.
On January 1 of the next year, everything starts over again.
If you're talking about homeowner's insurance and "coinsurance", the concept is very different.
Posted: Sat Nov 20, 2010 01:40 am Post Subject:
yea makes full sense.
Posted: Sun Dec 19, 2010 08:35 pm Post Subject: insurance question
On a $20,000 in hospital medical bill for an individual with a policy that says $2,500 individual deductible with Maximum out of pocket expenses in calendar year of $5,000 plus, 70/30 coinsurance for inpatient / surgery mean to mean in simple to understand terms?
Thanks Rich
Posted: Mon Dec 20, 2010 07:01 am Post Subject:
$20,000 total bill
- 2,500 deductible
_______
$17,500 amount subject to coinsurance
x 0.30 coinsurance percentage
_______
$ 5,250 out of pocket expense
$ 5,000 stop loss/maximum out of pocket expense means the insurance company will pay the additional $250 plus 100% of all additional (later) medical expenses for the insured in the year.
Having said this, some policies include the deductible in the total out of pocket expense for the stop loss. But I doubt that is the case in your policy. It most likely will work as I have illustrated.
Posted: Fri Dec 31, 2010 12:18 pm Post Subject: Health insurance
BCBs plan 90/10 plan. has a $250.00 deductible plus
a 10% coinsurance in Florida.The broker is pushing this plan. I found Preferred Medical of Coral Gables that has
no deductibles nor coinsurance. But the broker said the
company has problems. No complaints filed in Tallahassee concerning this company
who do I believe
Posted: Fri Dec 31, 2010 04:47 pm Post Subject:
the broker said the company has problems
Ask the broker to prove his allegations, or talk to someone at Preferred Medical. I don't know anything about them, but I cannot find anything negative about them either. For what it's worth (not much), BBB of Coral Gables rates Preferred Medical Plan, Inc. "A+". Probably wouldn't be the case if they "had problems".
It is a violation of most states' insurance laws to "defame" an insurance company in a manner that causes persons to not do business with them. The reason your "broker" may have made the remark is that he does not represent Preferred Medical Plan, Inc., or wants to earn a (higher?) commission by enrolling you in the BCBS plan.
If the broker cannot document his accusation, then you should turn and RUN from that person, and file a complaint about them with the state Dept of Insurance. He may not have your best interest in mind . . . as the law requires.
Posted: Tue Jan 11, 2011 06:05 pm Post Subject: Full roof replacement
Company to be given work by insurance company has asked us for the deductible amount before work has begun. Is this unusual ? Work should be finished before deductible is paid I believe.
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